CS Form No.

7
Series
Seriesofof2017
2017
DEPARTMENT OF EDUCATION
Division of La Union
CLEARANCE FORM
(Instructions at the back)

I PURPOSE

November 10,2022
Date of Application
TO: ATTY. DONATO D BALDERAS, JR
I hereby apply for clearance from money, property and work-related accountabilities for:
Purpose: £ Transfer £ Resignation £ Other Mode of Separation:
£ Retirement £ Leave Please specify: __________________________
November 23,2022 - February 22, 2022
Effectivity/Inclusive Period:________________________________________

Office of Assignment: Cabaroan Elementary School

MARCIANA A. SANCHEZ
Position/SG/Step: TEACHER II- SG 12 Name and Signature of Employee
II CLEARANCE FROM WORK-RELATED ACCOUNTABILITIES
We hereby certify that this applicant is cleared of work-related accountabilities from this Unit/Office/Dept.

ESTELA T. CARIASO MARCIANO N. ORFIANO _

___ Name and Signature of School Head Name and Signature of Public Schools District Supervisor / Unit Head
___
III CLEARANCE FROM MONEY AND PROPERTY ACCOUNTABILITIES
Not
Name of Unit/Office/Department Cleared Cleared
Name of Clearing Officer/Official Signature
1. Administration Sector

Supply and Property Procurement and MA. LEILANI S. CORTEZ

a. Management Services Administrative Officer IV

DOMINGA N. LIM, Ph.D.

b. Human Resource Welfare & Assistance Administrative Officer V

c. Agency-accredited Union/Cooperative
2. Library

a. Legal Office Library

CLAIRE P. TOLUYEN
b. Library Services Librarian
3. Finance and Assets Management
CRISTEL MAE A. BADUA
Accountant III
a. Financial Services
GILDA R. ANCHETA
(Transaction, Processing & Billing Services) Administrative Officer IV
b. Cash and Money Accountability
JOSE RHETOR C. REYES
Human Resource Management Officer
c. Payroll & Remittance Services
4. Professional and Institutional Development
LODIVINA B. BAYANI
SeniorEducation Program Specialist
a. Scholarship Services
IV CERTIFICATION OF NO PENDING ADMINISTRATIVE CASE:
ATTY. PAMELA JANE P. DE GUZMAN
a. Internal Affairs Office/Legal Affairs Office Attorney III

with pending administrative case

with ongoing investigation (no formal charge yet)

V CERTIFICATION

ATTY. DONATO D. BALDERAS JR.

Schools Division Superintendent
Signature over Printed Name of Agency Head

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INSTRUCTIONS:

1. Employees who are retiring, being separated, transferring to other agencies,

leaving the Philippines and going on maternity leave of absence shall prepare
this form in quadruplicate.

2. This clearance should be duly accomplished before paying the last salary or
any money due the employees. (Specify which type of clearance: maternity
leave, retirement, transfer, etc.)

3. If the employees are cleared from a unit/office/department, the

clearing/authorized official may attach to this clearance the pertinent
document/s that shall prove that the employees are cleared of any obligation
or accountability from their office, if any, and tick the box under the "Cleared"
column before affixing their signatures.

4. If the employees appear to have uncleared accountability/ies from a

unit/office/department, the clearing/authorized official shall attach to this
clearance the pertinent document/s that shall prove that the employees have
remaining obligation or accountability from their office further indicating the
necessary action/s that the employee must satisfy in order to be cleared, and
tick the box under the "Uncleared" column. The clearing/authorized official
must only sign this clearance corresponding to their name once the employee
have complied the necessary requirements and cleared of all the obligation/s
and accountability/ies from their office. They must also tick the box under the
"Cleared" column.

5. The HRMO shall distribute copies of approved clearance as follows: original to

the employee; duplicate to be attached to the payroll or voucher; triplicate to
human resource unit file; and fourth copy to accounting/auditing office.

6. Processing of clearance certificate shall follow the order of number indicated.

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